Adrian Johnson

Date of report	20 Dec 2013
Reference	2013-0364
Deceased	Adrian Johnson
Coroner	Andrew Harris
Coroner area	London Inner (South)
Category	State Custody related deaths
Source	judiciary.uk record · original PDF
Responses published	1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Re: Inquest touching the death of Adrian Johnson dod 13" May 2010, Case
number: 01259/2010, concluded 6" December 2013.

THIS REPORT IS BEING SENT TO:

1. Mr Michael Spurr, Chief Executive Officer, National Offender Management
Service

2. BE (cad of Public Health, Armed Forces Health and
Offender Health NHS England

3. a 2: of Health Care, HMP Belmarsh

CORONER

| am Andrew Harris, senior coroner for the jurisdiction of London Inner South

CORONER'S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST

By a majority, the jury found that Mr Adrian Johnson died by an act of accidental
hanging between 12.50 and 13.55 on 13" May 2010 in the Segregation Unit of HMP
Belmarsh.

CIRCUMSTANCES OF THE DEATH

1. Circumstances related to initial screenings in the First Night Centre:

The jury concluded that Mr Johnson died in part from serious failures within the prison
system. His initial screenings within the First Night Centre failed to highlight the urgent
need for a mental health assessment and did not ensure his medication needs would be
met and failed to take appropriate heed of Adrian Johnson’s exceptional dependency on
nicotine, the single trigger recorded on the already open ACCT.

2. Circumstances related to ACCT Reviews:

The jury found that the ACCT Review on the morning of 43" May 2010 was
inadequately conducted, in the absence of clinical records, with no appropriate
psychologist present as per HMP Belmarsh Suicide Prevention Policy and the
omission of the solicitor’s letter from the family, received into Health Care Unit on
the 12° May 2010. The reduction in the level of observations and relocation into a
non-gated cell prior to securing the overdue mentai health assessment amounted to
neglect. On the balance of probabilities the ACTT Review failed to maintain
adequate protection for a highly vulnerable inmate with a history of recent impulsive
self harm (Two out of ten jurors objected to the use of the term impulsive in the
absence of any mental health assessment being conducted).

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to concern in
each of these areas:

Circumstances related to initial screenings in the First Night Centre:

The nurse conducting the primary reception screen said that she could not ask
questions about smoking or withdrawal as she was not toxicology trained.

The doctor fo whom Mr Johnson was referred in the First Night Centre by the
nurse, said that she did not routinely assess smoking habits and that she
expects the matter to be covered by nurses. She does not get involved in
tobacco issues.

The nurse who conducted the secondary screen recorded the number of
cigarettes that she said he smoked, but did not ask any questions about
withdrawal.

The mental health nurse who later saw Mr Johnson, on referral by the doctor
said that smoking was not his area; he assumed it was assessed in reception.

There was no health care worker who assessed whether he had problems with
withdrawal from tobacco. According to the exert witness, Dr| who was a
GP with substantial experience working in prisons, for this patient, withdrawal
and agitation due to lack of tobacco was obviously an issue. He said that
nicotine withdrawal was very important in this case, increasing the patient's
vulnerability and anxiety and thus his risk.

Dr saic that this prisoner had made it very clear that, although a
majority of prisoners can manage their tobacco withdrawal, he could not, so that
vigilance should have been higher and greater steps taken to support this, which
becomes highly relevant when we see him moving to health care, which is a
smoke free environment. He said that he would have treated him with a patch or
lozenges to reduce anxiety, or he might use Diazepam. There was a
prescription of Diazepam, but it was not in the dose being given in the previous
prison and police station on transfer, it was not administered when the
prescriber intended and was not prescribed for tobacco withdrawal.

Dr EEE who was Chair of the RCGP Secure Environments Group, advised
that tobacco use should be screened for as part of the reception screen in the
first 24 hours, including a question as to whether tobacco withdrawal might be a
problem. He was sufficiently concerned that without such a question in routine
use in prisons, there was a potential risk to future lives and recommended that |
should make a prevention of deaths report, to those named.

Circumstances related to ACCT Reviews

The ACCT review on 11/05/2010 chaired by Officer A, was held without input
from health care, despite the main trigger for his self suspension days earlier
being anxiety related to tobacco withdrawal.

The court heard that a governor did not know that the prisoner was on an open
ACCT when he was informed of his initial transfer to the segregation unit

qd)

There was a lack of consistency in case management, with no handover from
case manager Officer A (who was not informed or invited to the subsequent
reviews) to the case manager of the ACCT review on 12/05 or to the ACCT
review with a third case manager, chaired by the governor on 13/05. This
appeared not be in compliance with PSO guidance.

The attendees for enhanced care team review on 13/05 were not selected by
the governor, who was in the chair, who left the invitations to the Segregation
Unit. A psychologist was not invited, contrary to local guidance. Health care was
invited at the last minute with no notice to prepare.

The health care member attended with very little knowledge of the case. He did
not know that there was an alcohol abuse history and did not discuss his
personality disorder, possible prior diagnosis of schizophrenia or potential
withdrawal problems. He did not know of the Diazepam prescribing prior to
admission or at Belmarsh. It was not clear that the review team had been
informed of an admission by the prisoner that the recent ligature was a serious
attempt on his life. A LISA form was completed at reception, giving details of
Diazepam dependency, alcohol abuse, past history of schizophrenia, previous in
patient psychiatric care and current antidepressants but this information was not
available to the Review teams

The listed Caremap areas for consideration were not all considered. Action to
link the person to people who can provide support did not include his family
(after the two minute reception call). Actions to encourage alternatives to self
injury, to reduce emotional pain caused by practical problems, action to reduce
vulnerability because of mental health problems and action to reduce
vulnerability because of drug and alcohol problems were either not or
inadequately considered. The governor agreed that he had not conducted a
comprehensive careplan.

Many of those actions required mental health assessment, which was not
conducted before he died, which the expert said should have been done in
48hrs of admission, and not doing it was a really serious failure. The last ACCT
review did not consider whether or when it would be done.

The last Review agreed the reduction of observations to hourly, without any
information from mental health assessment. The governor had not seen the
entry in the prison records that Mr Johnson was at high risk of impulsive
behaviour causing accidental suicide. Had he known that, he would have asked
for the results of the mental health assessment prior to downgrading his
observations

The expert was critical of the decision to keep him in Segregation Unit, in the
light of his vulnerability and health problems. {t was not clear that all other
options had been fully explored: this was not an item considered at the last
ACCT Review.

The MATTERS OF CONCERN are as follows. -

(1) Expert opinion has been given that the failure to routinely screen for and enquire
into tobacco withdrawal as part of prison reception screening creates risks to the
lives of a small number of vuinerable prisoners. Withdrawal problems may be
interpreted by staff as behaviour designed to gain benefits, unless an
appropriate health care assessment is conducted. Health care staff at HMP
Belmarsh do not appear to be trained to conduct such screening, nor manage
withdrawal, nor is it clear whose responsibility it would be.

To questioning about steps that HMP had taken to reduce future risks, a
governor reported a significant improvement in the conduct of ACCT reviews
and pleasing spot checks. However she could not confirm whether there had
been any individual learning by those involved. It was not clear that there would
be any better consistency of case management in prisoners who move to the
Segregation Unit, nor in the way in which members were asked to attend, nor
the adequacy of caremap planning. The discipline staff appeared to blame the
health care staff for the incomplete health care information at reviews, but there
was no indication that they accepted that the case manger and chair had
responsibilities to secure the information if it was not volunteered. It remained
unclear how decisions on reduction of observations would in future be fully
informed in exceptional cases where vulnerable prisoners are in the Segregation
Unit. Improvements in the processes and conduct of ACCT reviews may not
have fully addressed the areas of concern, which create significant risks for
vulnerable prisoners

ACTION SHOULD BE TAKEN

(1) NOMS and NHS England are asked to consider the expert opinion on the risks
associated with tobacco withdrawal and consider whether any national initiative is
required to include screening in the reception process, or issue appropriate guidance.
HMP Belmarsh health care is asked to be mindful of the identified risks and advice of
these bodies.

(2) HMP Belmarsh is asked to review the areas of concern that were raised in this
inquest, in relation to the adequacy of the ACTT Review process and either take
appropriate action or report on the steps taken already to address these areas.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 14 February 2014. |, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following Interested
Persons:

Ms EE next of kin

Ms Treasury Solicitors for Prison Service
Mr Radcliffes Le Brasseur for Dr H Kucper
M Mills & Reeve for Virgin Care Ltd

Ms EE Royal College of Nursing for Nurse
and to Dr fF who may find it useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner.

If _ would like further information _ = = " ™ “i my officer, ma

[DATE] [SIGNED BY CORONER’

Zor hecomber 20(3 i

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Noms (PDF)

i,
a Equality Rights and Decency Group
at National Offender Management Service
. Ministry of Justice
National Offender Post Point 4.11, 4th Floor
70 Petty France

Management Service. London

SW1H SHD

28 February 2014

Dr Andrew Harris
HM Coroner — Inner South District of Greater London

Dear Dr Harris

Thank you for your Regulation 28 report addressed to the National Offender Management
Service (NOMS), NHS England (NHSE), and the Governor of HMP Belmarsh. Equality,
Rights and Decency Group responds to all Regulation 28 correspondence as we have the
policy responsibility for suicide prevention and self-harm management, and for sharing
learning from deaths in custody. Please accept this as a response from NOMS (including
HMP Belmarsh) and NHSE, who has been consulted about this response.

You identified a number of issues in your letters which I have addressed below in the order
which they were raised.

NOMS and NHS England consider the Coroner's expert’s opinion on the risks
associated with tobacco withdrawal.

Both NOMS and NHSE agree that, while comprehensive assessments are completed when
a prisoner is received into prison custody in relation to their health and risk of harm to self
and others, further consideration needs to be given to the extent to which screening
processes should identify tobacco dependence and potential issues associated with
withdrawal. Currently, prisoners undergo a number of assessments on their arrival in prison
custody. Prison Service Order (PSO) 3050 “Continuity of Healthcare for Prisoners, contains
a mandatory requirement that requires that “an initial assessment of the healthcare needs of
all newly received prisoners is undertaken within 24 hours of first reception by an
appropriately trained member of the healthcare team to identify any existing problems and to
plan any subsequent care. A health screen..takes place before the prisoner's first night to
primarily detect:

° immediate physical health problems
® immediate mental health problems
° significant drug or alcohol abuse

* risk of suicide and/or self-harm

The policy requires that if immediate health needs are detected, the prisoner is referred to
the appropriate healthcare worker or specialist team. In addition, in the week following first
reception, every prisoner must be offered a general health assessment. This assessment is
equivalent to a primary care assessment when registering with a new practice in the
community. Such assessments are not standardised, however the general health
assessment should act as an opportunity for:

° gathering further medical information
* checking how the prisoner is settling in
* health education

. providing information
. health promotion

As you will recall from the evidence at the inquest, the second reception screening includes
a review of the prisoner's smoking habits and how many cigarettes he/she smokes daily.
The prisoner is asked whether he/she wishes to stop smoking and is offered help to do so.
Smoking cessation Programmes, which include the provision of nicotine replacement
therapy, are available to every prisoner throughout his or her time in custody, and further
evidence given explained how diazepam can be prescribed if necessary to alleviate the
effects of tobacco withdrawal.

In addition, Prison Service Instruction 74/2011 ‘Early days in custody — reception in, first
night in custody, and induction to custody’, includes the requirement for an initial screening
in relation to the prisoner's mood: “The prisoner must.. be interviewed, in private if possible,
to discover and record any further immediate needs and tisks, and any other information
about the prisoner that may be relevant, particularly during their first night in custody’.
Furthermore, it requires that “The PER and any other available documentation including
Suicide & Self Harm Warning Forms, ACCT decuments and CSRA assessments, must be
examined, and the prisoner interviewed in Reception, to assess the risk of self-harm or harm
fo others by the prisoner, or harm from others’.

NOMS accepts that despite the above range of screening during the reception process,
further consideration needs to be given to identifying prisoners for whom tobacco withdrawal
may give rise to an increase in suicidal feelings or self-harm, and to develop the’ support
given to prisoners who do not have access to tobacco, or to the amount they would normally
rely on. NOMS is currently working with healthcare partners to develop a care pathway, that
includes an appropriate level of screening, to ensure that when tobacco is not available, or it
is available but in more limited supply than the level they are used to (because they have
limited funds/access to prison shop), that the relevant healthcare provider ensures that
appropriate support, including Nicotine Replacement Therapy is available. This is recognised
as especially important in cases of poly substance users and those with mental health
issues,

In addition, you will be interested fo know that the Offender Health and Tobacco Cessation
Teams at Public Health England (PHE), are currently working on guidance for Prisons in the
management of people with nicotine addictions. As this guidance is not yet completed, PHE
recommends that healthcare providers responsible forthe assessment and treatment of
tobacco withdrawal follow the NICE Public Health Guidance (PH45) on Tobacco Harm
Reduction, which recommends that when tobacco is not available, or it is available but in
more limited supply, that Nicotine Replacement Therapy is made available to supplement
tobacco use. Facilitating access to extra nicotine can prevent users from experiencing
nicotine withdrawal and the side effects that this may cause.

HMP Belmarsh review the areas of concern regarding the implementation of ACCT, that
were raised during the inquest.

ACCT case reviews.

National policy contained within PSI 64/2011 “Management of prisoners at risk of harm to
self, to others and from others (Safer Custody)” reminds staff of the mandatory requirement
that ACCT case reviews “Be muilti-disciplinary where possible”. Colleagues at HMP Belmarsh
have. confirmed that the Governor and all managers (including custodial managers and
supervising officers) will attend further ACCT Case Manager refresher training, in part to
underline the importance of a multidisciplinary attendance at case reviews, and the need to
seek contributions from relevant departments, including healthcare staff and mental health

professionals. This refresher training will commence this month and is expected to be
completed by October 2014.

In terms of attendance at ACCT case reviews, the policy recognises that “The ACCT process
will operate more effectively if there is continuity in the attendance of staff from relevant
departments/services. For example, if education is seen as a relevant department to attend the
review, then every effort should be made to ensure the same member of staff attends the
reviews, likewise with healthcare input”. The Enhanced Case Review Team will involve all
relevant disciplines and include more specialists and a higher level of operational
management than a typical ACCT Case Review Team. Colleagues at Belmarsh have
confirmed that the refresher training will remind all managers that ahead of any planned moves,
the ACCT Case Manager will undertake a handover with the new Case Manager at the new
location, and the importance of both ACCT Case Managers attending the case review prior
to the relocation will be reiterated, In addition, Case Managers will also be reminded of the
need to gather all relevant information and to allow those attending ACCT case reviews to
review the ACCT and any risk related information they may possess (for example, on
SystmOne) which the Review Team need to be aware of.

Within the ACCT process, the ACCT Assessor is expected to gather and review all available
tisk related information including that contained within the NOMIS notes, the F2050
(prisoner's core record), and any recent ACCTs etc, to inform the assessment. All relevant
risk information should be recorded within the ACCT, and attendees at the first ACCT case
review and subsequent case review meetings are expected to be familiar with the contents
of the ACCT. You will be aware that the Prisons and Probation Ombudsman recommended
that a local protocol was devised to ensure that information was shared between safer
custody and healthcare staff, and as a result members of the mental health in-reach team
now record interaction with prisoners subject to on open ACCT both on SystmOne and
within the ACCT document. Case Managers have been reminded of the need to follow up
any mental health referrals and are now required to follow up any referrals to ensure that it
has been received and actioned — this will also be addressed in the current ACCT refresher
training, in the local policy on Suicide Prevention (which is due to be re-issued on 10 March
2014) and a Notice to Staff to be issued on 3 March 2014,

National policy requires that staff ensure that a case manager or a representative from the
receiving residential unit is invited to attend a case review ahead of a planned relocation
within the prison, the purpose of which is to ensure that all relevant information and risk is
shared and understood.

ACCT CAREMAPS

Chapter 5 of PS! 64/2011 sets out the purpose of the ACCT case review which include:

Consider and record progress against the initial CAREMAP, and the Prisoner's general well-
being;

Consider whether the prisoner exhibits any additional needs which may require the CAREMAP
to be updated:

Discuss with the prisoner the meaning of any acts of self-harm-and options for alternative
coping strategies.

Colleagues at Belmarsh have confirmed that ACCT case managers will be reminded during
the ongoing ACCT refresher training and in the updated local policy of the requirement to
review the CAREMAPS at each case review and record the manager who is responsible for
each action and who is required to feed back at the next case review.

A review of the records on SystmOne and the CAREMAP should have highlighted the fact
that Mr Johnson had been referred for a mental health assessment, but this had not been
completed.

Location in the searegation unit.

Policy allows prisoners subject to ACCT procedures to be located in the segregation unit in
“exceptional circumstances. The reasons must be clearly documented in the ACCT Plan and
include others options that were considered but discounted”. In Mr Johnson's case, staff in
the healthcare centre were concerned that Mr Johnson had become aggressive, and was
threatening to damage and “kill someone’ if he remained there. Staff were concerned that he
therefore presented a danger to other patients, and his perceived attempt to assault the
Governor led to his relocation in the segregation unit.

While it is apparent that the Governor who authorised the segregation was not aware of Mr
Johnson’s ACCT or the potential triggers when he was relocated from the residential unit to
the segregation unit, his risk was recognised by the Nurse completing the initial segregation
safety algorithm (which requires confirmation of an open ACCT, as well as signs that they
are acutely unwell) and accepted by the Governor. The reasons for him being relocated to
the segregation unit were documented by those attending the enhanced case review team
who (as the PPO reported) thought he should remain there due to the outstanding charges
(concerning the damage to his cell and his attempted assault on the Governor), and also
because he was permitted to smoke there, which case review team recognised remained an
extremely important concern to him.

It is acknowledged in policy and accepted by colleagues at HMP Belmarsh that prisoners
who are subject to ACCT procedures should be located in segregation units only in
exceptional circumstances, and that this point will be reinforced during the ongoing ACCT
refresher training.

| hope you find this fetter helpful.

Yours sincerely,

uy

The report

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